GW1--05770_Well Construction - GW1_20230901

WELL_CONSTRUCTION RECORD
For faunal Else ONLY:.
. .a '171is.fanncan be used fer.single or multiple wells*
➢.WO1.1.Contractor Information: , •
:LJzWATERZONES 6
Stefan Smith FROM'. TO DESCRIPTION
Weil Cor taWor Name. ft. ft. f
3576A
ft, ff.
NCnrcllConimclorCcrii@®lionNunbcr ',t5;'O11TER-CASING'(fbr®idti-ra~edssetis1VRL[NER(ifinli ileybk)` ..-
FRoM ' TO ' DIASfETRn - THICKNESS ' MATERIAL
SAEDACCO • 0 it. 10 ft' 2 ht. SCH-40 PVC
Comp;uq-tr'autr • 16.iNNERCASING'OR>TUHING:k8ailuimatckasil.168,0-'-- -
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construetinn Penult#: 2023-20-05—MW-5—RWO ft. ft. '� .
Li till applica61e list!pCniditz(P:¢.Colrnn,,Mimi,t,irianer.Ireecdr4 cr J.
•• ft.. . •• ft, :' .
3:Wc11 Use(chi?elcwebuse),: . :•f7:SCREEN . •
Water Supply1,14cll: FROM I TO 1 DIAMETER St.OTSi7.E THICKNESS I MATERIAL
. o1Agticultttal Dtiiiu►icipalll'uhiic 10 ft. 25 fr. 2 in O10 SCH-40 PVC
INetititemtat(Heating/Cooling-Supply') DRcsiidential-Water Supply(single) fi. .ft:. .in,
Dlndsl triaUCoulnuercial ®Residential Water.Supply(skated) '1 8 GR1UT: .._ „ .;_ ;'_.. . . , .•
FROM . TO. MATERIAL EMPLACEMLNT METHOD&.L\OUNT
Cl lrripltinn• . . 0 ft. 6 fr. . Portland Pour
Non=Water Supply WON: f • (t. .
t.
• ElMaltitoring pitccnsi sty
[n]edlon Weil:
ft. . It. '
Cl Aquifer Rectintge Clci[ontid rucr Rcnlcdlation =[9YSANI11GRAVEL'PACK7ifuiiplipbkr'-'== - —- .
• "TeliO\I • 10 •MATERIAL ' tiMPI.;tCr\li:V7'Mt.-luau •
-
Dr>,gniferStorugc-at l Record)', DSalinity Harrier 8 R. 25 ft. sand 2
D Aquifer Test DStontici;rtecl}nriitagC It ft. . .
OEapctinrcntal Toclrnoto .. OSttbsidcncc,Cwiimt -
2obRILLtNG'LOG7nttacli-hultinnalshectsif'ncccsszfe.6-
DGeot ennal(Closed Loop) DTraeer FROM TO DEScRIPTlON itutsr.trnnlntn,Wei;'nkti nor:cndn s3 a sir l
CiGeotliesinal(Heating/Cooling Return)- DOilter.(espIninuluter.#21-Retuarks) 0 ' .ft. 12 fi.1 Clayey' silt -
12 ft. 25• ft. Silt' s
e c � ` ; r\/F.. '!'d:Dat WeE(s)Coytpleted: 8-4-23We1E D#MW-4R �• _o i_,, !_r
-at
ft. I
54.Well Location: .f.. - rt. • ' S E P 0 ' 2023
Jimmy's:Daytona fL' ft infe.or,a5cm PinUfede..9 E)fl9i
- -FacilitylOis!nerNante Facility ll)k Cfappiiublc) R.-- -
ft. J 0(3
2001 W.-Vandalia Rd., Greensboro; NC, 27407 fA ft.. ' C -
•
Plnfsi",ad Address,Cit}'_and Zip 12 I::REMA1tKs.
Guilford Two foot bentonite seal from 6-8'
•
County' • Parcel kl.ntificallon No;(PIN) �,
.rill..Latititdc•andl.ongit de in dcgttes?mluutes&sceondsas decitratlddegre 234Certitication:
(if uell ftid,utx 13•00 iS•Sid i.ktd)
36.020487 N 79.839836 'y � 8/10/2023.
giguST Z161.,lied Well Caiuimctar; Date
6.IS(ore)the rvell(s):'x Pennancnt or DTentporur}' si5nirr.,his fain!,,.I hereby cerlr v Oar Mg wets.)Pats,(t+rre,)edd,id referl lnstrordance
with 1 M WAG'OTC.0100 or 254 NC4C72C;0300 We Consmictiror Slum tads and ulna a
7.is this a repair:to an ci istingivt:ll: DYe iir No 'tsriOofdris rrrroiyllrns'lees limvidcd in ii"r.sir!!limier,
If thls:It a rip*.All 4W kr;inrda Hill c orutrar(1tora hVororol)on miff r tp{aht the aware of the
reOairrariler 021-remarks srcii in or on the bark of this form. 23:Site dilagram or adititiona1w.pl/tletails:
You mv use the back of this page to:provide•additionat well site.details.or Well
S:finmherof il'el(s cottifrueted: 1 consinictlml details: You.inay also attach additional pines if necessary"
For nrult!lxrc lrrfe lulu e r um-miter supply is lts ONLY frith rhe.sane corrstru Lion,you evgrr
sabnritmie form. - SUBINCPCAL iNST1JCTJONS i'
9.Totat well depth hetoiv land stirftice: 25 ((i.) 21a..For All Weil,:" Suhtiiit this form within 30 days of compktiou of•well
For Judd*ii:tls'EsrafldrpthsIfellffwoalexrurlyte-.3@2ftrarui.2@10,p) consfnictior_itolltefollowiugg: I' ' -
10.Static water lei'el heluw lop of easiimi IN Division of WaterRi sourtcs,[nfircntatiun Piticessing Unit,
if ttsilvr ki°ci is rthove eas(ay,suit"t" 1617 hUtil.Sin'ice;Cciitcr,Raleigh,NC•27699-I617 •
8..25"
II.Durellotc diameter. (in.) tab:For bliccillyn W cll�ONLY: 'in addition to sending:itte farm to the address in
24a aboie,also ssibntit a•.copy of this fonts trithis 30•dabs of completion of Welt
12.Well'construction method:'USA • collstilieliau to the following:-
{i c.3u ,eerily,cable,direct posts.etc.} Dtvlsion of Water-Resources,;Uodet'g and[tijection Control Program,
FOR WA ITRSit'PPLY WELLS ONLY:' -1636 Mail Service'Center,Raleigh,NC 27699-1636 '
13a,V(cld( {m) Method of test: '-lc-For Water Supply.&Inlect[oa.,Welts: '
Also submit one'copy of this'fault Within.6`day's of cotupletion.of
1311.Disinfection¢Apo: Amount: well.constmetion to the county health department of'the county where.
constructed.
Fond GW-1 Ninth Comilla i epanatenrof Fuviromucm aid Natural Resources—Division of Water R'.uttte: Rcviscd.Augtnt 21113
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